Power Medical

Seafarer Application

Rank Surname *st Name(s)

Date of Birth Place of Birth Nationality

Marital Status No. of Children Phone

Mobile Phone

Full Address

E-Mail Address

Nearest Airport Availability Date

Next of kin Relationship Phone

Address

Education Year completed

Identity-/ Travel Documents Nationality Type Number Place of Issue Issued Expiry Passport

US-Visa

Other Visa

Seaman Book

Seaman Book

Medical Certificates Nationality Type Number Place of Issue Issued Expiry Certificate of Medical Fitness

Yellow Fever Vaccination

Certificates - Courses Nationality Position Number Place of Issue Issued Expiry Certificate Of Competence

Certificate Of Competence

Certificate of SSO

General Operator Cert. (GMDSS)

Basic Safety Training

Proficiency Survival Craft

Proficiency Fast Rescue Boats

Advanced Fire Fighting

Medical First Aid

Medical Care

HAZMAT (US-Trading)

ARPA

ECDIS

Experience-Knowledge Subject or Hard- / Software Self Evaluation (please tick) Language Knowledge English Good Satisfactory Nil / Poor Language Knowledge Good Satisfactory Nil / Poor

Electr. Chart Display System Good Satisfactory Nil / Poor Computer Experience Microsoft Windows Good Satisfactory Nil / Poor Computer Experience Microsoft Office (Word, Excel) Good Satisfactory Nil / Poor Stability / Cargo Planning System Seacos Good Satisfactory Nil / Poor Other Stability / Cargo System Good Satisfactory Nil / Poor Planned Maintenance System CODie ISMAN Good Satisfactory Nil / Poor Other Planned Maintenance Syst. Good Satisfactory Nil / Poor Working Experience Monitor / Maintain Reefer Containers Good Satisfactory Nil / Poor Working Experience Operate / Maintain Ship's Cranes Good Satisfactory Nil / Poor Working Experience Automation Systems Good Satisfactory Nil / Poor Working Experience Common Rail M.E. Good Satisfactory Nil / Poor Working Experience ISM - Systems / - Audits Good Satisfactory Nil / Poor Please state Nationalities of Seafarers you sailed with: Senior Officers

Junior Officers

Ratings

Sea-Service (most recent vessel first)

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

Vessel Type GRT DWT TEU

From To Main Engine

Make - Type

Power

kW

Vessel's

Flag

Rank

Employer Charterer Trading

Area

By sending this application I am accepting below terms and condition: 1) I hereby affirm that all the information provided by me is true and correct to the best of my knowledge and belief. I further affirm that no certificate of Competency or License issued to me has ever been revoked or suspended. I understand that previous employers may be asked for information concerning my employment record with them and I hereby release from liability or damage those individuals or companies who provide such information. 2) I hereby agree to the use of my personal data included in my job application as acquired by the recruiting process (according to the Polish law of August 29,1997 in respect of a protection of personal data Dz. Ust. Nr 133 poz.833).

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